Aspiration is a serious concern in any healthcare setting, as it can have severe consequences for patients. In order to prevent aspiration, nurses must be able to identify patients at risk and implement interventions to reduce that risk. The NANDA nursing diagnosis of “Aspiration Risk” is used to identify patients who are at risk for aspiration and to guide nursing interventions to prevent it.
NANDA Nursing Diagnosis Definition
According to NANDA International, the official definition of “Aspiration Risk” is: “The potential for the patient to inhale foreign material into the lungs, as evidenced by factors such as impaired swallowing, altered level of consciousness, or impaired ability to protect the airway.”
Defining Characteristics (Subjectives and Objectives)
- Impaired swallowing, such as difficulty swallowing or coughing during meals
- Alterations in level of consciousness such as confusion or disorientation
- Impairments in the ability to protect the airway, such as difficulty controlling secretions
- Symptoms such as shortness of breath, chest pain, or fever
- Previous history of aspiration
Related Factors
- Age-related changes in swallowing or cognitive function
- Chronic illnesses or conditions that affect swallowing or airway protection
- Medications that can cause drowsiness or confusion
- Neurological disorders such as stroke or Parkinson’s disease
- Surgeries or procedures that affect swallowing or airway protection
- Environmental factors such as poor lighting or inadequate positioning during meals
Risk Population
Individuals who are at a higher risk for aspiration include:
- Elderly individuals
- Individuals with chronic illnesses or conditions that affect swallowing or airway protection
- Individuals taking medications that can cause drowsiness or confusion
- Individuals with neurological disorders such as stroke or Parkinson’s disease
- Individuals who have recently undergone surgeries or procedures that affect swallowing or airway protection
- Individuals in a care setting, such as a hospital or nursing home, where they may be more likely to be exposed to environmental hazards that can contribute to aspiration
Associated Problems
Aspiration can lead to a number of serious problems, including:
- Pneumonia
- Aspiration pneumonitis (inflammation of the lungs caused by the aspiration of foreign material)
- Respiratory distress or failure
- Sepsis (a potentially life-threatening infection that can spread throughout the body)
- Death
Suggestions for Use
To prevent aspiration, nurses should take the following steps:
- Assess the patient’s risk for aspiration by taking a thorough history and identifying any potential risk factors.
- Implement safety measures to reduce the patient’s risk of aspiration, such as providing appropriate positioning during meals or administering medication to control secretions.
- Educate the patient and their family about the risks of aspiration and how to prevent it.
- Monitor the patient’s condition and report any changes to the healthcare provider immediately.
- Administer appropriate treatments and interventions, such as suctioning or administering antibiotics.
Suggested Alternative NANDA Diagnoses
- Impaired Swallowing
- Impaired Gas Exchange
- Impaired Verbal Communication
- Impaired Swallowing related to neurological disorders
- Impaired Swallowing related to Mechanical Ventilation
Usage Tips
- This diagnosis should be used in conjunction with other diagnoses that may be contributing to the patient’s risk of aspiration, such as Impaired Swallowing or Impaired Verbal Communication.
- It is important to monitor the patient’s response to interventions and adjust as necessary.
- It is also important to consider the patient’s overall health history and any previous experiences with aspiration.
List of NOC Results with Explanation
- Airway Management: This outcome measures the effectiveness of interventions in maintaining the patency of the patient’s airway and preventing aspiration.
- Swallowing: This outcome measures the patient’s ability to safely swallow food and liquids, and the effectiveness of interventions to improve swallowing function.
- Breathing Pattern: This outcome measures the patient’s ability to maintain normal breathing patterns and the effectiveness of interventions to improve breathing function and prevent aspiration.
- Nutrition Status: This outcome measures the patient’s nutritional status, including their ability to maintain appropriate weight and hydration, and the effectiveness of interventions to improve nutrition and prevent aspiration.
- Infection Control: This outcome measures the patient’s risk of infection, including the risk of aspiration pneumonia, and the effectiveness of interventions to reduce the risk of infection and prevent aspiration.
List of NIC Interventions with Explanation
- Airway Management: This intervention involves maintaining the patency of the patient’s airway and preventing aspiration through techniques such as suctioning and positioning.
- Swallowing Therapy: This intervention involves providing therapy to improve the patient’s swallowing function and prevent aspiration.
- Breathing Assistance: This intervention involves providing assistance with breathing, such as administering oxygen or providing mechanical ventilation, to prevent aspiration.
- Nutrition Management: This intervention involves managing the patient’s nutrition to improve their overall health and prevent aspiration.
- Infection Control: This intervention involves implementing measures to reduce the patient’s risk of infection, including the risk of aspiration pneumonia.
Conclusion
The NANDA nursing diagnosis of “Aspiration Risk” is a crucial tool for identifying patients at risk for aspiration and implementing interventions to prevent it. By understanding the diagnosis and related factors, nurses can take appropriate action to promote safety and prevent aspiration in at-risk patients.